Developing a set of consensus indicators to support maternity service quality improvement: using Core Outcome Set methodology including a Delphi process.

OBJECTIVE: To develop a core metric set to monitor the quality of maternity care. DESIGN: Delphi process followed by a face-to-face consensus meeting. SETTING: English maternity units. POPULATION: Three representative expert panels: service designers, providers and users. MAIN OUTCOME MEASURES: Maternity care metrics judged important by participants. METHODS: Participants were asked to complete a two-phase Delphi process, scoring metrics from existing local maternity dashboards. A consensus meeting discussed the results and re-scored the metrics. RESULTS: In all, 125 distinct metrics across six domains were identified from existing dashboards. Following the consensus meeting, 14 metrics met the inclusion criteria for the final core set: smoking rate at booking; rate of birth without intervention; caesarean section delivery rate in Robson group 1 women; caesarean section delivery rate in Robson group 2 women; caesarean section delivery rate in Robson group 5 women; third- and fourth-degree tear rate among women delivering vaginally; rate of postpartum haemorrhage of ≥1500 ml; rate of successful vaginal birth after a single previous caesarean section; smoking rate at delivery; proportion of babies born at term with an Apgar score <7 at 5 minutes; proportion of babies born at term admitted to the neonatal intensive care unit; proportion of babies readmitted to hospital at <30 days of age; breastfeeding initiation rate; and breastfeeding rate at 6-8 weeks. CONCLUSIONS: Core outcome set methodology can be used to incorporate the views of key stakeholders in developing a core metric set to monitor the quality of care in maternity units, thus enabling improvement. TWEETABLE ABSTRACT: Achieving consensus on core metrics for monitoring the quality of maternity care.

Preadolescent children of substance-dependent fathers with antisocial personality disorder: psychiatric disorders and problem behaviors.

We compared psychiatric disorders and problem behavior scores in pre-adolescent children of fathers with alcohol or other drug dependence and ASP (SD+/ASP+), children whose fathers had substance dependence without ASP (SD+/ASP-), and children whose fathers were without either disorder (SD-/ASP-). SD+/ASP+ children showed elevated rates of major depression, conduct disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, and separation anxiety disorder when compared to SD+/ASP- and SD-/ASP- children. SD+/ASP+ children had higher internalizing and externalizing problem behavior scores than the other two groups of children. The results suggest that SD+/ASP+ children are at significant risk for internalizing and externalizing psychopathology.

Treatment of childhood-onset schizophrenia with olanzapine.

This paper reports on a clinical observation of 15 hospitalized youths ages 6-13 years diagnosed with childhood-onset schizophrenia and acutely treated with olanzapine. Initial sedation was the most common side effect observed. Youngsters who had not had a previous trial on any psychotropic did better than those that had failed a previous medication trial. Age was inversely correlated with positive response to olanzapine. Patients who experienced initial sedation did best once the initial sedation wore off. The majority of patients in the study improved on olanzapine.

Crowding and violent behavior: the influence of patient density on violent and self-harming behaviour at a medium secure unit.

This study examines the influence of patient density (crowding) and number of potential perpetrators on the number of incidents of violence and self-harm at a medium secure unit. Of 2,053 incidents examined over a period of 974 days, 73% were perpetrated by 20% of the patients, the majority by patients identified as potential perpetrators. Increased patient density was not associated with increased risk of violence or self-harm. There was no evidence to suggest that the presence of those identified as potentially violent or self-harming increased the risk of others engaging in such behaviour.

Timing of hysterectomy surgery during the menstrual cycle--impact of menstrual cycle phase on rate of complications: preliminary study.

To determine the relationship between the timing of a hysterectomy performed during the menstrual cycle phase and the postoperative complication rate in women who had undergone surgery for dysfunctional uterine bleeding, the authors examined the charts of 24 patients for the 3-month period immediately after the hysterectomy. Twelve of the women were in the follicular phase, and 12 were in the luteal phase at the time they had undergone the hysterectomy. Patients were classified by operative pathology report. No significant differences (P < or = 0.05) were found between the two groups with respect to age, weight, para status, pathology, preoperative and postoperative hemoglobin levels, operation time, blood loss, days before return to full functioning, days in hospital, and uterine morphology. Further prospective studies with longer follow-up time are needed to obtain more conclusive indications regarding the optimal timing of hysterectomy during the menstrual cycle.

Pseudologia fantastica, factitious disorder and impostership: a deception syndrome.

Pseudologia fantastica and impostership are not currently included in diagnostic systems, although there is an overlap between these two syndromes and factitious disorder. A case which illustrates the overlap is described, and the diagnostic dilemma is discussed. A term 'deception syndrome' is proposed for those individuals who pathologically deceive for internal (i.e. psychological) as opposed to external reasons such as financial gain.

Unmet needs of remand prisoners.

A needs assessment protocol which examines 11 problem areas was devised. This was administered to 277 prisoners on remand at Brixton Prison. We found high levels of unmet need for housing, treatment of substance abuse and neurotic symptoms. Twenty-nine per cent were transferred to hospital under the provisions of the Mental Health Act and about a third of those at liberty to do so complied with a discharge plan. Diversion and discharge planning can potentially meet the unmet needs of remand prisoners.

African-Caribbean men remanded to Brixton Prison. Psychiatric and forensic characteristics and outcome of final court appearance.

BACKGROUND: African-Caribbean men are over-represented in psychiatric and forensic services and in the prison population. A failure of community services to engage mentally ill African-Caribbean men and their presentation through the criminal justice system culminates in a repeated pattern of forensic service and criminal justice system contact. METHOD: We carried out a cross-sectional survey during a one-year period of a sample of potentially mentally ill men remanded to HMP Brixton in south London. Men were interviewed to establish their place of birth, first language, socio-demographic profile, ethnicity, psychiatric diagnosis, levels of alcohol and substance misuse, criminality, violence involved in their index offence, past psychiatric and forensic contacts and outcome of court appearance. RESULTS: Two hundred and seventy-seven men were interviewed. In comparison with White men, African-Caribbean men were more often diagnosed as having schizophrenia and were more often sent to hospital under a mental health act order. African-Caribbean men were remanded in custody despite more stable housing conditions and more favourable indices of lifetime criminality, substance misuse and violence. CONCLUSIONS: Community services, including diversion schemes, should be especially sensitive to African-Caribbean men with schizophrenia who 'fall out of care', who are not diverted back into care and are therefore unnecessarily remanded.

Near death experiences: critical care nurses' attitudes and interventions.

A patient is successfully resuscitated after a trauma or serious illness. It is increasingly common for such a patient to report having experienced a feeling of calm and peace, a feeling of being separated from the body, and/or a sense of moving through a dark tunnel ending at a bright light. Such experiences are known as near death experiences. What are critical care nurses to make of such accounts reported to them by their patients? This article explores critical care nurses' interests in, knowledge of, and attitudes towards the near death experience, and it identifies nursing interventions that critical care nurses can use during and after the patient experiences near death.

African Caribbean men remanded to Brixton prison: psychiatric and forensic characteristics and outcome of final court appearance

AIMS: This study aims to examine the influence of ethnic origin on the range of diagnoses, past psychiatric and forensic contacts, and outcome of final court appearance in a random sample of men remanded in Brixton prison health care centre for a psychiatric assessment. METHOD: 277 men were randomly sampled from all men to HMP Brixton and referred to prison health care centres for a psychiatric assessment over a one year period. Men were interviewed immediately after remand to establish their socio-demographic profiles, their psychiatric diagnoses, alcohol and substance misuse histories, criminality, seriousness of index offence and violence involved in their index offence, past psychiatric and forensic contacts and outcome after court appearance. CONCLUSIONS: In this sample, a greater percentage of black men who were remanded in custody had a diagnoses of schizophrenia. They were remanded despite more stable housing and fewer criminal convictions than the white group. Custodial remands could be avoided if community services (psychiatric diversion) were especially sensitive to the needs of black men with severe mental illness.(AU)

Readability of advance directive documents.

PURPOSE: To assess the readability of advance directive documents. DESIGN: Descriptive. SAMPLE: Convenience, 10 advance directive documents from various sources. METHODS: Advance directive documents were electronically scanned in 1994 then evaluated using three readability formulas: Flesch-Kincaid Grade Level, Flesch Reading Score, and Gunning's Fog Index. FINDINGS: The average readability (in school grade levels) of the 10 documents was 11.3 using the Flesch-Kincaid Grade Level and 18.2 using the Gunning's Fog Index. CONCLUSIONS: All documents were above reading levels usually recommended for patients. CLINICAL IMPLICATIONS: Patients must be able to read and understand advance directive documents before signing them. Refinement of the documents is recommended to support patient understanding and autonomy in end-of-life care.

Readability of written materials: implications for critical care nurses.

Written materials are given to patients every day in critical care units. Unfortunately, some of the materials are written at a reading level that is too difficult for patients to read. Patients and families need understandable materials to help them make the difficult decisions they face.

Possible association of interleukin-2 treatment with depression and suicide.

Immunomodulatory agents for the treatment of certain oncologic disorders are rapidly moving from the research laboratory into clinical practice. These agents may not be void of potential neuropsychiatric sequelae. The following clinical report concerns a previously nondepressed patient with no history of psychiatric disorders who became depressed and killed himself while being treated with interleukin-2. It is important that consulting psychiatrists be sensitive to acute emotional changes in cancer patients taking immunomodulatory agents.